Is the patient covered by commercial insurance coverage?*
Yes
No
Does the patient reside in the United States or Puerto Rico?*
Yes
No
Is the patient who will use this coupon eligible for reimbursement
of prescriptions (in whole or in part) under any federal, state or
other governmental programs, including, but not limited to,
Medicare (including Medicare Advantage and Part A, B and D plans),
Medicaid, TRICARE, Veterans Administration or Department of
Defense health coverage, CHAMPUS, the Puerto Rico Government
Health Insurance Plan or any other federal or state healthcare
programs?*
Yes
No
Patient Privacy Authorization
I authorize my child's healthcare providers and staff, pharmacies,
and health insurers to use and to disclose to Sobi, Inc., and its
affiliates, business partners, vendors, and other agents
(collectively, “Sobi”) health information about my child,
including information related to my child's medical condition and
treatment, health insurance and coverage claims, and prescription
(including fill/refill information) for SYNAGIS (“Information”) to
(1) enroll my child in and provide services under the SYNAGIS
CONNECT™ patient support program (the “Program”); (2) obtain
information on my child's insurance coverage; (3) coordinate
prescription fulfillment as indicated by my child's physician; (4)
provide me with adherence reminders and support; and (5) contact
me to conduct market research and to arrange for my receipt of
educational, promotional, and/or marketing materials about Sobi
support programs or Sobi products. Once my child's Information has
been disclosed to Sobi, I understand that federal privacy laws may
no longer protect it from further disclosure. However, I also
understand that Sobi will protect my child's Information by using
and disclosing it only for the purposes allowed by me in this
Authorization or as otherwise required by law.
I understand and agree that the pharmacy that dispenses SYNAGIS
may receive payment from Sobi in exchange for disclosing my
child's Information to Sobi and providing Program services.
I understand that I do not have to sign this Authorization. A
decision by me not to sign this Authorization will not affect my
child's ability to obtain medical treatment from healthcare
providers, eligibility for health insurance benefits, or access to
Sobi medications. However, if I do not sign this Authorization, I
understand my child will not be able to participate in the
Program.
I understand that this Authorization expires ten years from the
date signed below, or as otherwise required by state or local law,
unless and until I cancel (take back) this Authorization before
then. I may change my mind and cancel this Authorization at any
time by calling 1-833-SYNAGIS (1-833-796-2447) or by notifying
Sobi in writing at SYNAGIS CONNECT, PO Box 29076, Phoenix, AZ
85038-9076. Cancellation of this Authorization will end further
uses and disclosures of my child's Information and my child's
participation in the Program but will not affect any uses or
disclosure of my child's Information made by my child's health
care providers and staff, pharmacies, and health insurers based on
this Authorization before receipt of the cancellation. I
understand I may request a signed copy of this Authorization.*
I Agree
I Do Not Agree
By signing, I agree to be contacted by email at the address I have provided or to receive autodialed phone or text messages ("texts") at the mobile phone number I have provided for the purpose of helping me/the patient stay on therapy, which may promote or advertise Synagis. I certify that the number I am providing belongs to me and not a family member or third party. I understand that I may opt out of individual communications of the program entirely by calling 833-SYNAGIS, clicking the email link in a message received or by replying "Stop" by text to any text from Synagis Connect. Synagis Connect will not sell or rent this information and will use it only in accordance with this authorization and consent. Consent to being contacted by email, phone or text messages is not a condition of participation in the programs or the purchase of any products or services. I understand that my cellular service carrier's data and text messaging rates may apply. This authorization is valid for 2 years from the date the form is signed. If I am providing this consent on behalf of another person, I certify that I am authorized to agree to every element of this consent on behalf of such other person, and I agree that I will be liable and will hold SOBI Inc harmless in the event that such other person alleges that they did not give consent
I Agree
I Do Not Agree
By clicking the submit button, I am agreeing that all
information contained in this enrollment is complete and accurate*
I Agree
I Do Not Agree
By clicking the submit button, I am agreeing that I have read, understood and will comply with the terms and conditions of the program and that patient currently meets all eligibility criteria.
Limitations apply. Valid only for those with private insurance.
The program includes the copay card, payment card (if applicable)
with a combined annual limit of $6,000. Patient is responsible for
any costs once the dollar limit is reached during the program term
(July-June) calendar year. Program is not valid (i) under
Medicare, Medicaid, TRICARE, VA, DoD or any other federal or state
health care program, (ii) where patient is not using insurance
coverage at all, or (iii) where the patients' insurance plan
reimbursees the entire cost of the drug. The value of the program
is exclusively for the benefit of patients and is not intended to
be credited toward patient -pocket obligations and maximums,
including applicable co-payments, co-insurance and deductibles.
Program is not valid where prohibited by law. Patient may not seek
reimbursement for the value received from this program from other
parties, including any health insurance program or plan, flexible
spending account, or health care savings account. Patient is
responsible for complying with any applicable limitations and
requirements of their health plan related to the use of the
program. Valid only in the United States and Puerto Rico. This
program is not health insurance. Program may not be combined with
any third-party rebate, coupon, or offer. Proof of purchase may be
required. Sobi, Inc. reserves the right to rescind, revoke, or
amend the program and discontinue support at any time without
notice.